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Suspicious Axillary Lymph Nodes Identified on Clinical Breast MRI in Patients Newly Diagnosed with Breast Cancer

Posted Mar 31, 2015 Updated Apr 10, 2023
By Habib Rahbar MD , Jane L. Conlin MD , Sana Parsian MD , Wendy B. DeMartini MD , Sue Peacock MS , Constance D. Lehman MD PhD , Savannah C. Partridge PhD
14 min read

Rationale and Objectives

To determine whether quantitative dynamic contrast-enhanced (DCE) and diffusion-weighted (DW) magnetic resonance imaging (MRI) features can discriminate malignant from benign axillary lymph nodes (ALNs) identified as suspicious on clinical breast MRI in patients newly diagnosed with breast cancer.

Materials and Methods

After approval from institutional review board, all clinical breast MR examinations performed from March 2006 through January 2010 describing at least one morphologically suspicious ipsilateral ALN in patients with newly diagnosed breast cancer were identified. Each suspicious ALN underwent ultrasound-guided core needle biopsy, and nodes with benign results were subsequently sampled surgically. Quantitative DCE and DW MRI parameters (diameters, volume, enhancement kinetics, and apparent diffusion coefficients [ADC]) were measured for each suspicious ALN and a representative contralateral normal node, and each feature was compared between the ALN groups (normal, benign, and malignant).

Results

Thirty-four suspicious ALNs (18 malignant and 16 benign) and 34 contralateral normal-appearing ALNs were included. Suspicious malignant and benign nodes exhibited larger size, greater volume, and lower ADCs than normal ALNs ( P < .05). Among suspicious ALNs, the only quantitative measure that discriminated between malignant from benign outcome was percent of ALN demonstrating washout kinetics ( P = .02).

Conclusions

In ALNs deemed morphologically suspicious on breast MRI, quantitative MRI features show little value in identifying those with malignant etiology.

Axillary lymph node (ALN) status in patients newly diagnosed with invasive breast cancer provides vital prognostic information to guide therapy. In clinically node-negative women with T1 or T2 invasive breast cancer, determination of ALN status has evolved from routine surgical removal of all level I and II ALNs with complete axillary lymph node dissection (ALND) to the modern practice of selective surgical sampling of a few (typically less than five) level I ALNs to exclude the presence of axillary nodal metastases with sentinel lymph node biopsy (SLNB). This less-invasive strategy results in completion ALND in only those patients with SLNB-proven lymph node metastases, has proven to be highly accurate, and allows most patients to avoid ALND and its associated high rate of morbidity . The use of ALND is expected to decline further since recent data from the American College of Surgery Oncology Group (ACOSOG) Z0011 trial showed a lack of survival or locoregional recurrence benefit of completion ALND in clinically node-negative but SLNB-positive women .

Although surgical evaluation of the axilla continues to trend toward less-extensive operations, the role of imaging in axillary assessments needs to evolve with surgical technique accordingly. Several recent studies have suggested breast magnetic resonance imaging (MRI) features of ALNs , and breast primary malignancies may hold promise to confirm the presence or absence of metastatic ALNs. Because breast MRI is increasingly being used at centers for preoperative evaluation of patients newly diagnosed with breast cancer, this potential added benefit is appealing . However, given new trends in management of the axilla in the post-ACOSOG Z0011 era, determining the presence of one or more ALN metastases that are not clinically suspicious but are detected solely by imaging may provide less clinical utility than determining the number of disease-laden ALNs by SLNB. Thus, we sought to assess the ability of quantitative dynamic contrast-enhanced (DCE) and diffusion-weighted (DW) MRI features to improve the positive predictive value (PPV) of clinical breast MRI assessments of morphologically suspicious ALNs using direct pathology-to-imaging verification.

Materials and methods

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Patient Population

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MRI Technique

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Image Analysis

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(4/3π×abc)8 (

4

/

3

π

×

abc

)

8

where a, b, and c are the three orthogonal diameters (AP, ML, and SI).

Figure 1, A 57-year-old woman presented with a 26-mm invasive ductal carcinoma (IDC) in the left breast for a bilateral breast magnetic resonance imaging (MRI) to assess extent of disease with dynamic contrast-enhanced (DCE) and diffusion-weighted imaging (DWI) techniques. (a) Regional nonmass enhancement ( red circle ) is present in the left breast on maximum intensity projection image, site of biopsy-proven IDC ( red circle ) in the left breast. (b) Initial-phase postcontrast T1-weighted image with fat suppression demonstrates a morphologically suspicious level 1 axillary lymph node (ALN) in the left axilla ( vertical orange arrow ) and a representative contralateral morphologically normal level 1 ALN ( angled blue arrow ) in an analogous location. (c) Both the suspicious ALN ( vertical orange arrow ) and normal ALN ( angled blue arrow ) exhibit high signal intensity on DWI. (d) Both the suspicious ALN ( vertical orange arrow ) and normal ALN ( angled blue arrow ) are dark on ADC map (d) confirming the presence of restricted diffusion. (e) Sagittally oriented, contrast-enhanced, T1-weighted, fat-suppressed reformations demonstrate the morphology of the suspicious ALN ( vertical orange arrow ) in the breast ipsilateral to the IDC. (f) Morphology of the suspicious ALN on ultrasound ( angled orange arrow ) that ultimately underwent ultrasound-guided biopsy correlates well with morphologic appearance on MRI (b,e) . (Color version of figure is available online.)

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ADC=−(1b)ln(SDWIS0) ADC

=

−

(

1

b

)

ln

(

S

DWI

S

0

)

where b = 600 s/mm 2 , S DWI is the combined DW image (geometric average of individual b = 600 s/mm 2 DW images), and S 0 is the b = 0 s/mm 2 reference image.

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Ratio=[suspiciousALNvalue][normalALNvalue] Ratio

=

[

suspicious

ALN

value

]

[

normal

ALN

value

]

where ratio is the intrapatient ratio for a given MRI parameter, suspicious ALN value is the measured value for that MRI parameter for a given patient, and normal ALN value is the measured value for that MRI parameter for the same patient.

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ALN Ultrasound CNB Technique

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Histopathology

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Statistical Analysis

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Results

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Table 1

Index Tumor Characteristics for All Patients Included in the Study

Characteristic Benign ALN ( N = 16) Malignant ALN ( N = 18) Total ( N = 34) Maximum tumor size, mm; median (range) 17 (9–45) 18 (11–29) 17 (9–45) Tumor histology, n (%) DCIS 1 (6.3) 0 (0) 1 (2.9) IDC 13 (81.3) 15 (83.3) 28 (82.4) ILC 1 (6.3) 3 (16.7) 4 (11.8) Poorly differentiated carcinoma 1 (6.3) 0 (0) 1 (2.9) Nottingham Score, n (%) 1 2 (12.5) 2 (11.1) 4 (11.8) 2 5 (32.3) 6 (33.3) 11 (32.4) 3 7 (43.8) 10 (55.6) 17 (50.0) Not assessed (DCIS and poorly differentiated carcinoma) 2 (12.5) 0 (0) 2 (5.6) Estrogen receptor, n (%) Positive 6 (37.5) 12 (66.7) 18 (52.9) Negative 9 (56.3) 6 (33.3) 15 (44.1) Unknown 1 (6.3) 0 (0) 1 (2.9) Progesterone receptor, n (%) Positive 4 (25.0) 11 (61.1) 15 (44.1) Negative 9 (56.3) 7 (38.9) 16 (47.1) Unknown 3 (19.0) 0 (0) 3 (8.8) HER2/neu receptor, n (%) Positive 0 (0) 3 (16.7) 3 (8.8) Negative 12 (75.0) 14 (77.8) 26 (76.5) Unknown 4 (25.0) 1 (2.6) 5 (14.7) Ki-67 (%), mean (range) 53.8 (5–90) 38 (5–80) 45.4 (5–90)

DCIS, ductal carcinoma in situ; IDC, invasive ductal carcinoma; ILC, invasive lobular carcinoma.

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Suspicious Malignant Outcome Versus Normal ALN Comparisons

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Table 2

Comparison of Quantitative MRI Features of Malignant Versus Contralateral Normal Axillary Lymph Nodes (ALNs) in 34 Patients with Breast Cancer

Feature Malignant ALN, mean (SD) Normal ALN, mean (SD)P Value Kinetic features Peak enhancement (%) 440.6 (299.0) 324.8 (226.9) .11 Washout (%) 73.4 (20.9) 72.4 (20.7) .80 Size Angiographic volume (mm 3 ) 1.8 (1.9) 0.4 (0.3) <.0001 ∗ Manual volume (mm 3 ) 2.0 (1.7) 0.4 (0.3) <.0001 ∗ Maximum size (mm) 19.4 (5.2) 12.6 (5.7) .0008 ∗ Minimum size (mm) 10.6 (3.2) 5.7 (2.1) <.0001 ∗ DW MRI features Mean ADC (mm 2 /s) 1.01 (0.2) 1.14 (0.2) .02 ∗ Minimum ADC (mm 2 /s) 0.51 (0.2) 0.73 (0.3) .002 ∗

ADC, apparent diffusion coefficient; DW, diffusion weighted; MRI, magnetic resonance imaging; SD, standard deviation.

P values were calculated by Wilcoxon signed rank test.

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Figure 2, A 43-year-old woman with a new diagnosis of right breast Nottingham grade 2 invasive ductal carcinoma spanning 20 mm in maximal size presents for a bilateral breast magnetic resonance imaging (MRI) to evaluate extent of disease. A suspicious and ultimately biopsy-proven malignant ipsilateral axillary lymph node (ALN) was identified on the MRI. (a) The suspicious ALN ( arrow ) demonstrated diffuse cortical thickening and loss of fatty hilum on this T1-weighted contrast-enhanced image with fat suppression. (b) The suspicious ALN exhibited 308% initial peak enhancement with 83% delayed washout ( red color overlay ) on computer-aided evaluation. (c) The ALN exhibits high signal ( arrow ) on the b = 600 s/mm 2 diffusion-weighted image. (d) On apparent diffusion coefficient (ADC) map, the ALN is dark ( arrow ; mean ADC, 0.65 × 10 −3 mm 2s), indicating restricted diffusion. (Color version of figure is available online.)

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Suspicious Benign Outcome Versus Normal ALN Comparisons

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Table 3

Comparison of Quantitative MRI Features of Benign Versus Contralateral Normal Axillary Lymph Nodes (ALNs) in 34 Patients with Breast Cancer

Feature Benign ALN, mean (SD) Normal ALN, mean (SD)P Value Kinetic features Peak enhancement (%) 398.7 (225.9) 411.7 (470.7) .38 Washout (%) 88.4 (12.8) 82.8 (16.8) .4 Size Angiographic volume (mm 3 ) 3.2 (4.5) 0.5 (0.6) .001 ∗ Manual volume (mm 3 ) 3.5 (5.9) 0.8 (0.7) .0002 ∗ Maximum size (mm) 20.7 (9.9) 14.9 (6.3) .06 Minimum size (mm) 12.5 (5.3) 6.8 (2.8) <.0001 ∗ DW MRI features Mean ADC (mm 2 /s) 1.03 (0.2) 1.12 (0.2) .08 Minimum ADC (mm 2 /s) 0.44 (0.2) 0.69 (0.3) .003 ∗

ADC, apparent diffusion coefficient; DW, diffusion weighted; MRI, magnetic resonance imaging; SD, standard deviation.

P values were calculated by Wilcoxon signed rank test.

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Figure 3, A 40-year-old woman with newly diagnosed high nuclear grade ductal carcinoma in situ spanning 50 mm in the right breast presents for bilateral breast magnetic resonance imaging (MRI) to evaluate extent of disease. A suspicious and ultimately biopsy-proven benign (on both core needle biopsy and sentinel lymph node biopsy) ipsilateral axillary lymph node (ALN) was identified on the MRI. The asymmetrical size and suspicious morphology of this lymph node were presumed to be due to reactive changes from recent ipsilateral breast biopsy performed 1 week before the MRI. (a) T1-weighted, fat-suppressed, contrast-enhanced axial image demonstrates the suspicious ALN ( arrow ) measuring 29 mm in maximal size and exhibiting diffuse cortical thickening and loss of fatty hilum. (b) The suspicious ALN exhibited 308% initial peak enhancement with 83% delayed washout ( red color overlay ) on computer-aided evaluation. (c) On diffusion-weighted imaging (DWI), the ALN exhibits high signal on the b = 600 s/mm 2 image ( orange arrow ). (d) The suspicious ALN is dark on the apparent diffusion coefficient (ADC) map ( arrow ; mean ADC, 0.78 × 10 −3 mm 2s), indicating restricted diffusion. (Color version of figure is available online.)

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Suspicious Malignant Outcome Versus Benign Outcome ALN Comparisons

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Table 4

Comparison of Quantitative MRI Features between Benign and Malignant Morphologically Suspicious Axillary Lymph Nodes (ALNs)

Feature Benign ALN, mean (SD) Malignant ALN, mean (SD)P Value Kinetic features Peak enhancement (%) 398.7 (225.9) 440.6 (299.0) .63 Washout (%) 88.4 (12.8) 73.4 (20.9) .03 ∗ Size Angiographic volume (mm 3 ) 3.2 (4.5) 1.8 (1.9) .68 Manual volume (mm 3 ) 3.5 (5.9) 2.0 (1.7) .61 Maximum size (mm) 20.7 (9.9) 19.4 (5.2) .96 Minimum size (mm) 12.5 (5.3) 10.6 (3.2) .30 DW MRI features Mean ADC (mm 2 /s) 1.03 (0.2) 1.01 (0.2) .62 Minimum ADC (mm 2 /s) 0.44 (0.2) 0.5 (0.2) .39

ADC, apparent diffusion coefficient; DW, diffusion weighted; MRI, magnetic resonance imaging; SD, standard deviation.

P values were calculated by Mann–Whitney U test.

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Table 5

Comparison of Intraindividual Normalized Quantitative MRI Features between Benign and Malignant Morphologically Suspicious Axillary Lymph Nodes (ALN)

Feature Benign ALN, mean (SD) Malignant ALN, mean (SD)P Value Kinetic feature ratios Peak enhancement 1.43 (1.3) 2.0 (2.4) .26 Washout 1.12 (0.3) 1.11 (0.5) .96 Size ratios Angiographic volume ratio 1.17 (1.6) 1.05 (1.2) .77 Manual volume ratio 4.96 (5.0) 9.38 (16.4) .15 Maximum size 1.52 (0.7) 1.91 (1.3) .39 Minimum size 1.95 (0.7) 1.99 (0.8) .93 DW MRI feature ratios Mean ADC ratio 0.95 (0.2) 0.90 (0.2) .40 Minimum ADC ratio 0.70 (0.4) 0.85 (0.8) .99

ADC, apparent diffusion coefficient; DW, diffusion weighted; MRI, magnetic resonance imaging; SD, standard deviation.

All values are ratios of suspicious ALN-to-contralateral normal ALN, and thus, there are no units.

P values were calculated by Wilcoxon rank sum test.

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Discussion

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Conclusions

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Acknowledgments

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Academic Radiology, Volume 22, Issue 4
Journals General Radiology
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